Nancy M Allen LaPointe, Yuliya Lokhnygina, Gillian Sanders, Eric Peterson, and Sana Al- Khatib Is...
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Transcript of Nancy M Allen LaPointe, Yuliya Lokhnygina, Gillian Sanders, Eric Peterson, and Sana Al- Khatib Is...
Nancy M Allen LaPointe, Yuliya Lokhnygina, Gillian Sanders, Eric Peterson, and Sana Al-Khatib
Is Selection of Antiarrhythmic Drugs for Atrial Fibrillation Consistent with Guideline Recommendations: Results from a Large Contemporary Community Cohort
Background
Two general treatment strategies for atrial fibrillation – rate vs. rhythm control
In the rhythm control strategy, guidelines recommend antiarrhythmic drug (AAD) selection based upon presence of concomitant heart disease – HF, CAD, HTN, or none of the above
The degree to which clinical practice adheres to the guidelines is largely unknown Especially in younger patients with atrial
fibrillation
Objective
In a large, contemporary, community cohort consisting of AF patients < 65 years of age, assess: Proportion receiving AADs (rhythm control
strategy) Proportion within guideline specified subgroups Antiarrhythmic drug use overall and within
guideline designated subgroups
Methods: Data Source
Thomas Reuters Marketscan® Commercial Claims and Encounters Database Inpatient, outpatient, and prescription claims
database from employers and health plans in the US
Includes covered employees and their spouses and dependents
Does not include any Medicare claims dataAll patients < 65 years of age
Claims data obtained from 1/1/06 through 12/31/10
Methods: Overall Study Cohort
Inpatient or outpatient encounter with an AF diagnosis (427.31) First AF encounter identified as index AF
encounter Age > 30 years No ventricular arrhythmia diagnosis at any point in
time No cardiothoracic (CT) surgery within 30 days of
index AF encounter Subsequent AF encounter w/o CT surgery could
be selected as index AF encounter
Methods: Subgroups
Patients were then categorized into one of the four subgroups Heart failure or Cardiomyopathy. Coronary Artery Disease Hypertension None of these
Category determined by an inpatient or outpatient diagnosis In order presented above
Methods: Antiarrhythmic Drugs and Analysis
NDC codes used to identify all oral Class Ia, Ic, and III AAD
Prescription claim for > 30 days supply following index date considered AAD use
Analysis Describe AAD use with focus on use in
subgroupsAssess consistency between use in clinical practice and guideline recommendations
Results: Characteristics of Overall Study CohortCharacteristic No AAD
n=252, 397 (76%)AAD
n=78,877 (24%)
Age, median (IQR) 56 (50,61) 57 (52,61)
Men 62% 69%
Region Northeast North Central South West Unknown
17%28%38%16%2%
11%30%41%16%2%
Type of Health Plan HMO PPO POS Other
17%64%9%11%
15%66%9%
10%
Index AF encounter Inpatient Outpatient
17%83%
20%80%
Results: Proportion of index AF encounters with subsequent AAD Use by Year (i.e. “new starts”)
Results: Period Prevalence of AAD Use (Quarter)
Guideline Recommendations
Fuster V et al. Circulation 2011;123:e269-e367
Copyright © American Heart Association
Results: Proportion of AF patients in each subgroup with AAD Use by Year (i.e. “new starts”)
Incidence of AAD Use by Year of AF index event (i.e. “new starts”)
AFib
study Population
(n= 331,274)
No Heart Disease Subgroup
n=81,891 (25% )
Patients with AAD n=15,461 (19%)
17,326 AADs
Flecainide (33%)
Propafenone (22%)
sotalol (20%)
Amiodarone (14%)
Dronedarone (6%)
Dofetilide (3%)
HTN Subgroup
n=110,752 (33%)
Patients with AAD
n= 24,527 (22%)
28,317 AADs
Flecainide (26%)
Sotalol (22%)
Propafenone (21%)
Amiodarone (19%)
Dronedarone (8%)
Dofetilide (3%)
CAD Subgroup
n= 77,782 (23%)
Patients with AAD n=20,551 (26%)
24,678 AADs
Amiodarone (28%)
Sotalol (27%)
Propafenone (16%)
Flecainide (16%)
Dronedarone (9%)
Dofetilide (4%)
HF Subgroup
n=60,849 (18%)
Patients with AAD
n= 18,338 (30%)
22,266 AADs
Amiodarone (48%)
Sotalol (19%)
Propafenone (10%)
Dronedarone (9%)
Flecainide (9%)
Dofetiide (5%)
Green=First line Recommendation; Yellow=Second line; Red=Contraindicated
Results: Consistency between practice and guidelines
HF: Only 53% of AADs used were consistent with guideline recommendations Between 28% - 47% of AADs were
“contraindicated” CAD: Only 31% of AADs used were considered 1st
line and 28% were 2nd line 32% considered contraindicated
HTN and No heart disease subgroups: All AADs used were 1st or 2nd line with exception
of dronedarone (still not clearly incorporated into US guidelines)
Main Limitations
Study cohort included only insured patients from participating health plans Results may not be generalizable to uninsured
patients or patients from non-participating health plans
AAD use was determined by prescription claims Some patients may not have actually taken the
prescribed medication Study relies on the accuracy and completeness of
the submitted diagnoses codes
Summary
AAD use is not the dominant strategy in this cohort of patients < 65 years of age
Decreasing incidence of AAD use overall and within subgroups from 2006-2010
Increasing prevalence of AAD use overall and within subgroups from 2006-2010 Flecainide followed by sotalol had highest
prevalence in the overall cohort Numerous inconsistencies with guideline
recommendations Opportunities for targeted education/awareness Additional research